IntroductionThe term "dysfunction" as used in manual medicine terminology is defined as a reversible, functional restriction of motion of an individual spinal segment or as a peripheral articular malfunction presenting with hypomobility. The appearance of dysfunctions of the upper cervical spine can be the cause of localised or pseudoradicular pain as well as the cause of vertigo and impaired hearing via disturbances of the proprioception from the neck. The significance of dysfunctions of the upper cervical spine as one cause of vertigo and impaired hearing has been commonly discussed in ENT and neurology literature [5, 9-14, 20, 22-26]. Commentators in the field of manual medicine limit the influence of dysfunctions of the cervical spine as a cause of vertigo to upper cervical spine segments [8,16,27,28]. Dysfunctions below the motion segAbstract To our knowledge, quantitative studies on the significance of disorders of the upper cervical spine as a cause of vertigo or impaired hearing do not exist. We examined the cervical spines of 67 patients who presented with symptoms of dizziness. Prior to the orthopaedic examination, causes of vertigo relating to the field of ENT and neurology had been ruled out. Fifty patients of the above-mentioned group were studied. They followed the outlined treatment protocol with physical therapy and were available for 3 months of follow-up. Thirty-one patients, hereinafter referred to as group A, were diagnosed with dysfunctions of the upper cervical spine. Nineteen patients, hereinafter referred to as group B, did not show signs of dysfunction. Cervical spine dysfunctions were documented as published by Bischoff [4]. In group A dysfunctions were found at level C1 in 14 cases, at level C2 in 6 cases and at level C3 in 4 cases. In seven cases more than one upper cervical spine motion segment was affected. Dysfunctions were treated and resolved with mobilising and manipulative techniques of manual medicine. Regardless of cervical spine findings seen at the initial visit, group A and B patients received intensive outpatient physical therapy. At the final 3-month follow-up, 24 patients of group A (77.4%) reported an improvement of their chief symptom and 5 patients were completely free of vertigo. Improvement of vertigo was recorded in 5 group B patients (26.3%); however, nobody in group B was free of symptoms. We concluded that a functional examination of motion segments of the upper cervical spine is important in diagnosing and treating vertigo, because a non-resolved dysfunction of the upper cervical spine was a common cause of long-lasting dizziness in our population.

IntroductionDisc herniation leading to nerve root displacement with compression and causing radicular symptoms is only one of a variety of possible causes of lumbar and ischiadic pain. Pain radiating into the leg is not necessarily caused by irritation of the root [18,19]; Norman and May [25] identified the sacroiliac joint (SIJ) as one of the possible starting points of such complaints via injection of local anaesthetic. Disc herniations were detected on CT and MR scans in a high percentage of asymptomatic patients [5,16,17,31,32]. Likewise it has been shown that the size of herniations does not correlate with displayed clinical symptoms [6,8, 34]. If, despite the lack of sensory or motor losses, the incidental finding of pathologic disc morphology is concluded to be the source of pain, the wrong therapy may be initiated, e.g. nucleotomy, leading to unsatisfactory postoperative results [7,[28][29][30]. This has to be considered when a choice between surgical and non-surgical treatment is made.The lack of consideration of alternatives to disc-triggered pain is encouraged by the fact that some alternative diagnoses are undetectable by imaging procedures. Functional disorders in general, and dysfunction of the SIJ in specific, cannot be detected by CT or MRI. Reversible Abstract A dysfunction of a joint is defined as a reversible functional restriction of motion presenting with hypomobility according to manual medicine terminology. The aim of our study was to evaluate the frequency and significance of sacroiliac joint (SIJ) dysfunction in patients with low back pain and sciatica and imaging-proven disc herniation. We examined the SIJs of 150 patients with low back pain and sciatica; all of these patients had herniated lumbar disks, but none of them had sensory or motor losses. Forty-six patients, hereinafter referred to as group A, were diagnosed with dysfunction of the SIJ. The remaining 104 patients, hereinafter referred to as group B, had no SIJ dysfunction. Dysfunctions were resolved with mobilizing and manipulative techniques of manual medicine. Regardless of SIJ findings, all patients received intensive physiotherapy throughout a 3-week hospitalisation. At the 3 weeks follow-up, 34 patients of group A (73.9%) reported an improvement of lumbar and ischiadic pain, 5 patients were pain free. Improvement was recorded in 57 of the group B patients (54.8%); however, nobody in group B was free of symptoms. We conclude that in the presence of lumbar and ischiadic symptoms our presented data suggest consideration of SIJ dysfunction, requiring manual medicine examination and, in the presence of SIJ dysfunction, appropriate therapy, regardless of intervertebral disc pathomorphology. This could avoid wrong indications for nucleotomy.

Periprosthetic femur fractures are one of the most severe complications in hip surgery. Osteoporosis as seen in patients with rheumatoid arthritis could favour such fractures, which are located mostly between the stems of the hip and knee prostheses. A traumatic event is not even required. The fracture rate increases with predisposing factors, such as preliminary changes of the prosthesis or osteoporosis. This paper reports two patients with rheumatoid arthritis (males, 54 and 71 years old) with femur fractures after total hip and knee replacements. Both had a severe osteoporosis caused by a long-term steroid therapy. Consecutively, both patients showed refractures of the femur with loosening of the osteosynthetic material, so that a total femur replacement was required. However, both patients are able to walk. To reduce the risk of femur fractures between the tips of knee and hip prostheses it is advisable to use knee prostheses without a proximal intramedullary stem. In this way pressure stress is reduced.

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